TEVAR for traumatic thoracic injury with the first-generation
stent graft
Giovanni Tinelli, MD, PhD,aFabrizio Minelli, MD,aSimona Sica, MD,aFrancesca De Nigris, MD,a Massimo Massetti, MD,bandYamume Tshomba, MD,aRome, Italy
ABSTRACT
Thoracic endovascular aortic repair (TEVAR) is a life-saving treatment for blunt thoracic aortic injury. We report long-term outcomes of two young patients who underwent TEVAR for blunt thoracic aortic injury withfirst-generation thoracic stent grafts. The off-label use of the endograft affected the outcomes: one case of open surgery conversion due to an aortoesophagealfistula and one case of endovascular relining for a voluminous pseudoaneurysm associated with a type III endoleak. Long-term follow-up is crucial in TEVAR, especially in case of afirst-generation device used in an urgent setting. (J Vasc Surg Cases and Innovative Techniques 2021;7:16-20.)
Keywords: Thoracic endovascular aortic repair; Thoracic aortic injury; Thoracic aorta; Personalized medicine
Blunt thoracic aortic injury (BTAI) is a life-threatening emergency, usually resulting from a relevant decelera-tion at the aortic isthmus level, and it is reported that up to 80% of patients die instantly.1,2
Open surgical repair has been the standard procedure for BTAI since it was introduced in 1959.3This surgery con-sists of thoracotomy, systemic anticoagulation, use of cardiopulmonary bypass, and aortic cross-clamping. It re-sults in a high postoperative mortality rate and frequent major postoperative complications.4
In fact, several dilatative complications have been described after complex aortic surgery such as aneurysms and pseudoaneurysms and often a variety of procedures are needed, but the real fate of these complications is often only partially known.5,6
In 1997, Kato et al7were the first to report the use of stent grafts for BTAI. Over the last two decades, thoracic endovascular aortic repair (TEVAR) has become the gold standard treatment in these patients.8
Although TEVAR had been considered as a safe and a superior alternative to open repair,9severe complications may occur, including device-related complications, ischemic complications secondary to embolic events,
and graft infection with aortobronchial or aortopulmo-naryfistulation.10-12
However, TEVAR long-term results and efficacy remain unknown, mostly for young patients.
We describe long-term outcomes of two young patients treated with TEVAR for BTAI with the first-generation thoracic stent graft. The patients’ consent for publication was obtained.
CASE 1
A 34-year-old man underwent TEVAR with the EndoFit thoracic stent-graft system (LeMaitre Vascular, Inc, Burlington, Mass;Fig 1) due to a grade III (pseudoaneurysm) BTAI at the age of 19 years in 2002 after a car accident. The patient did not undergo a regu-lar scheduled follow-up, and 15 years after thefirst treatment, he presented with an acute onset of severe back and chest pain, he-moptysis, and fever. The computed tomography angiography (CTA) and the esophagogastroduodenoscopy showed afistula between the aortic stent graft and the esophagus (Fig 2). The gastric cavity was full of blood clots. Open late conversion was highly recommended. Surgery was performed by left thoracot-omy, with extracorporeal circulation. The stent graft was explanted, the aorta was reconstructed with a 28-mm gelatin-sealed Dacron graft (Gelweave; Vascutek Terumo, Renfrewshire, Scotland;Fig 1,B), and the aortoesophagealfistula was repaired. The postoperative course was complicated by early reintervention for hemostasis revision due to a massive bleeding, caused by laceration of the ascending aorta. At early follow-up, we found dysphonia and paralysis of the left vocal cord caused by open repair that required speech therapy cycles and lipofilling surgery of the vocal cord with partial voice rehabilitation.
CASE 2
The second case that we report is a young man who under-went TEVAR for grade III BTAI after a motor vehicle accident at the age of 26 years in 1997. A 100-mm-long stent graft con-structed from modified Z-stents covered with expanded polyte-trafluoroethylene graft material was deployed in proximal landing zone 3.13 The patient did not perform the planned
From the Unit of Vascular Surgery,aand Unit of Cardiac Surgery,bFondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore.
Author conflict of interest: none.
Correspondence: Giovanni Tinelli, MD, PhD, Unit of Vascular Surgery, Fonda-zione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, 00168 Rome, Italy (e-mail: giovanni.tinelli@policlinicogemelli.it).
The editors and reviewers of this article have no relevantfinancial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.
2468-4287
Ó 2020 The Author(s). Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jvscit.2020.08.035
regular follow-up over time, and after 21 years from the endovas-cular procedure, a CTA showed an asymptomatic voluminous pseudoaneurysm of the post-isthmic thoracic aorta with a maximum diameter of 60 mm with a type III endoleak (Fig 3).
A proximal relining TEVAR in proximal landing zone 313with Conformable Gore TAG Thoracic Endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz), using a bilateral femoral percuta-neous approach, was performed. The procedure was carried out
under three-dimensional fusion imaging in our hybrid room (Fig 4), with lower costs in terms of X ray and contrast medium exposure.14 The postoperative computed tomography (CT) scan showed the complete exclusion of the pseudoaneurysm dilatation (Fig 5).
The patient was discharged on the third postoperative day. After 1 year, the patient underwent a CT examination that showed no signs of endoleak or graft migration.
Fig 1. Volume rendering of thoracic endovascular aortic repair (TEVAR) with the EndoFit thoracic stent-graft system (A) and volume rendering of aortic reconstruction with a gelatin-sealed Dacron graft (B).
Fig 2. Multiplanar reconstruction showing the aortoesophagealfistula after thoracic endovascular aortic repair (TEVAR).
DISCUSSION
Aortic injury is the second most frequent cause of death in cases of blunt traumatic injury.15 TEVAR has an increasing role in the treatment of BTAI, with a lower rate of mortality, spinal cord ischemia, and renal failure with respect to the traditional open surgical repair. Current Society for Vascular Surgery clinical practice guidelines recommend the use of TEVAR for grade II-IV and nonoperative management for grade I BTAI.8
In consideration of the severity of the traumatic pa-thology and the reduced frequency in which it occurs, data comparing open repair and TEVAR are limited, and there are no randomized controlled studies comparing the two interventions. Harky et al9 in their systematic review and meta-analysis demonstrate a significant survival rate at 30 days and 1 year with the use of TEVAR. Indeed, TEVAR quickly became a univer-sally accepted alternative to conventional open surgery.16
TEVAR for BTAI is associated with a 7.3% in-hospital mortality in Vascular Quality Initiative, and independent risk factors for mortality include age, male gender, renal impairment, left subclavian artery involvement, and over-all injury burden.8
In terms of reintervention, in Harsky’s meta-analysis, there was no difference between TEVAR and open repair; the reintervention in the TEVAR group was related to endoleaks, whereas in the open repair cohort, the main cause of reintervention was bleeding. Howev-er, there are scarce data regarding the long-term follow-up.
A rare but extremely serious complication is repre-sented by the aortobronchial or pulmonary fistula. The incidence of eitherfistulizations in the entire cohort after TEVAR is reported to be approximately 0.56% in the literature.11,12
In our cases, the patients were very young and, at the time of treatment, a few cases of TEVAR had been car-ried out, especially for aortic trauma, as a life-saving treatment.
Fig 3. Volume rendering and multiplanar reconstruction of thoracic endovascular aortic repair (TEVAR) that shows a type III endoleak.
Fig 4. Relining thoracic endovascular aortic repair (TEVAR) under three-dimensional fusion imaging.
18 Tinelli et al Journal of Vascular Surgery Cases and Innovative Techniques
It is important to analyze the limitations of TEVAR for BTAI that determined serious complications, especially in long-term follow-up. Although the devices used in these patients were off label and implanted at a time before commercially available, the complications asso-ciated with these repairs are certainly applicable to modern devices and highlight the importance of long-term follow-up. In the majority of cases, patients with BTAI are young, with a small aortic diameter, and with focal lesions requiring a very limited aortic coverage, without the oversizing generally used in the aneurysmal pathology. Life expectancy in these young patients is very long, and then the follow-up should be tighter and longer than other treatments. However, a specific surveillance program for patients with BTAI treated with TEVAR has not yet been established. To make the follow-up more effective and pursued, we suggest that one way to reduce the exposure of patients to X rays could be an alternation between the angio-CT ex-amination and the transesophageal echocardiogram. We recommend performing thefirst CTA 1 month after the procedure and, in the absence of complications, at 12 and 24 months. Then, we propose to alternate a transesophageal echocardiogram to a CTA every 2 years lifelong. The patient must be adequately informed of his condition and of the surgical treatment to which he has undergone to make himself part of the complex follow-up process that will inevitably accompany him throughout his life. In light of these considerations, the follow-up must be conceived as an integral part of the treatment that finds its completion only in the long term.
CONCLUSIONS
TEVAR is the first choice of treatment for traumatic isthmic rupture. Our reports highlight the need for continued and tight surveillance of patients after TEVAR, especially in the case offirst-generation devices used in
an urgent setting, or in case of young people with a long-term follow-up expectancy.
REFERENCES
1. Parmley LF, Mattingly TW, Manion WC, Jahnke EJ. Non-penetrating traumatic injury of the aorta. Circulation 1958;17: 1086-101.
2. Buz S, Zipfel B, Mulahasanovic S, Pasic M, Weng Y, Hetzer R. Conventional surgical repair and endovascular treatment of acute traumatic aortic rupture. Eur J Cardiothoracic Surg 2008;33:143-9.
3. Passaro E, Pace WG. Traumatic rupture of the aorta. Surgery 1959;46:787-91.
4. Cowley RA, Turney SZ, Hankins JR, Rodriguez A, Attar S, Shankar BS. Rupture of thoracic aorta caused by blunt trauma: afifteen year experience. J Thorac Cardiovasc Surg 1990;100:652-60.
5. Tshomba Y, Bertoglio L, Marone EM, Melissano G, Chiesa R. Visceral aortic patch aneurysm after thoracoabdominal aortic repair: conventional vs hybrid treatment. J Vasc Surg 2008;48:1083-91.
6. Tshomba Y, Melissano G, Civilini E, Setacci F, Chiesa R. Fate of the visceral aortic patch after thoracoabdominal aortic repair. Eur J Vasc Endovasc Surg 2005;29:383-9.
7. Kato N, Dake MD, Miller DC, Semba CP, Mitchell RS, Razavi MK, et al. Traumatic thoracic aortic aneurysm: treat-ment with endovascular stent-grafts. Radiology 1997;205: 657-62.
8. Mohapatra A, Liang NL, Makaroun MS, Schermerhorn ML, Farber A, Eslami MH. Risk factors for mortality after endo-vascular repair for blunt thoracic aortic injury. J Vasc Surg 2020;71:768-73.
9. Harky A, Chan JS, Wong CH, Bashir M. Open versus endo-vascular repair of descending thoracic aortic aneurysm dis-ease: a systematic review and meta-analysis. Ann Vasc Surg 2019;54:304-15.
10. Pang D, Hildebrand D, Bachoo P. Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury. Cochrane Database Syst Rev 2019;2: CD006642.
11. Czerny M, Reser D, Eggebrecht H, Janata K, Sodeck G, Etz C, et al. Aorto-bronchial and aorto-pulmonaryfistulation after thoracic endovascular aortic repair: an analysis from the
European Registry of Endovascular Aortic Repair Compli-cations. Eur J Cardiothorac Surg 2015;482:252-7.
12. Marone EM, Baccari P, Brioschi C, Tshomba Y, Staudacher C, Chiesa R. Surgical and endovascular treatment of secondary aortoesophagealfistula. J Thorac Cardiovasc Surg 2006;131: 1409-10.
13. Mitchell RS, Ishimaru S, Ehrlich MP, Iwase T, Lauterjung L, Shimono T, et al. First International summit on thoracic aortic endografting: roundtable on thoracic aortic dissection as an indication for endografting. J Endovasc Ther 2002;9: 98-105.
14. Tinelli G, De Nigris F, Minelli F, Flore R, Santoliquido A, Tshomba Y. Endoanchors under 3D image fusion for a type IA endoleak after EVAR. Clin Case Rep 2019;7:529-32. 15. Patelis N, Katsargyris A, Klonaris C. Endovascular repair of
traumatic isthmic ruptures: special concerns. Front Surg 2017;4:32.
16. Iannelli G, Piscione F, Di Tommaso L, Monaco M, Chiariello M, Spampinato N. Thoracic aortic emergencies: impact of endovascular surgery. Ann Thorac Surg 2004;77:591-6. Submitted Jun 1, 2020; accepted Aug 27, 2020.
20 Tinelli et al Journal of Vascular Surgery Cases and Innovative Techniques
